When Your ER Visit For A Cold Becomes A 17-Page Fax To Me

The very idea that a bad cold you have checked out in the emergency room translates into thousands of dollars in health care expenses–and 17 pages of medical records faxed to me–should tell you something’s wrong with the health care system.

I’ll explain how this happens, but first here are two of the most common health care complaints I hear:

From doctors of all specialties: “All I do is sit in front of my computer, endlessly entering meaningless data. EMRs (electronic medical records) add hours to my day, sometimes killing my evenings too. I know it doesn’t contribute anything to anybody’s health—it’s just insurance-required paperwork so we’ll get paid.”

From patients: “I came into the examining room and the doctor barely glanced up at me. She spent the entire time staring at her iPad, asking questions, pointing, clicking, and commenting on how slow the system was. Then she stood up, said she’d emailed a prescription to my pharmacy, and left.”

A brief history of medical record keeping (aka patient chart notes)
When I was in medical school, I was taught that if you worked alone as a primary care doc, you kept just enough notes to enable yourself to keep track of your patients over the years. The notes didn’t need to be complicated, and you usually wrote them in a sort of shorthand of your own creation.

If you joined a group of doctors, you had to write clearly enough so that other physicians could decipher your notes. Longer observations (such as surgical operative reports or hospital summaries) could be dictated to a secretarial pool located somewhere in the bowels of the hospital.

To translate, patient presents with an upper respiratory infection, her physical exam is unrevealing, her strep test is negative, and the visit ended with self-care advice–probably aspirin, lozenges, and cough syrup.

In other words, two or three lines at most.

By the late 1960s, patients were getting more complex in ways that hadn’t existed a few years earlier. Now it was important to follow cholesterol levels, blood pressures, and tobacco use. In addition, medical groups were larger, there were more diagnostic tests and specialists, and, hovering in the background, malpractice attorneys. I remember late in my residence training being told to “do more tests and write down more data about each patient.”

When you hear the term “defensive medicine,” that’s it.

SOAP notes
All this writing led to medical records filled with lengthy descriptive paragraphs, until in the late 1960s someone invented a patient chart system dubbed SOAP notes, still taught in medical school and still quite useful, even in the current transition to EMRs. Let’s break down the acronym…

S The patient’s subjective emotional and physical complaints about a specific problem. “I have a terrible cold” is an S item. If you have two problems (“I also have a yeast infection”), that merits a second S note. If you have ten problems, each gets covered during your visit and in the SOAP notes.

O The doctor’s objective findings from the physical exam, including comments about lab results and x rays pertinent to that problem.

A The doc’s assessment (diagnosis) of your condition.

P The doctor’s plan to deal with your condition.

SOAP issues are numbered, so that SOAP #1 is your cold, #2 your yeast infection, and so on.

Obviously, SOAP recording took a lot more handwriting, especially when I went into geriatrics, where every patient appeared to have at least ten problems and each visit seemed to add another. But most doctors today agree that the SOAP system remains useful for organizing the note-taking process. Really, as obsessive as SOAP notes appear on the surface, we do like them!

System changes lead to the 17-page emergency room fax
And now the situation has shifted again. Medical malpractice has become much less of a threat, but physician notes are longer than ever. Why?

Because now doctors write their notes for health insurance company chart auditors.

Here’s an important part: Physicians are reimbursed by insurance companies based on the complexity of their interaction with the patient. This doesn’t necessarily mean just the amount of time spent, but also how many issues need to be addressed, how detailed the examination is, and whether lab reviews are done or specialists must be notified, etc.

So if you arrived at your doctor’s office today with a cold and your doc were practicing like we did in the late 1950s, she’d see you and then either collect cash or bill your insurer for a “simple visit,” for which she’ll be paid at a minimum rate. In a situation like this, if you ever wondered why you saw your doc (or her assistant) for only five minutes, it’s because she’s being paid for about five minutes of her time.

But…if you go to your primary care doctor’s office for a cold and also have high blood pressure, psoriasis, are overweight, smoke, take Prozac, etc., she’ll then write a SOAP note on each of these, bill your insurer for a significantly higher amount of money, and likely (and rightfully) collect it. Instead of being paid just for your cold, she’ll be paid for six more diagnoses.

However–and this is the big however–your insurance company may want to see evidence that she’s actually doing (as per her chart notes) all that she’s billing them for.

The backstory
During your visit, your doctor is pecking out a lot of stuff on her computer for two main reasons. First, there’s always the very remote chance your chart could end up in a malpractice suit. And second, she’s preparing for a possible inspection (audit) by a representative of your health insurance company. Because there are a lot of insurance companies, there are a lot of auditors these days.

Auditing could (and did) occur regularly during pre-EMR days, but not to the extent that it’s being done now. The increase in insurance watchdog behavior has been brought on by the system itself—so much money is involved, and so many players are there to take their share, that the insurance companies are trying to reduce costs. Of course, as for-profit companies this translates to increasing corporate profits. Only the preternaturally naïve think that chart auditing has anything to do with improving health care quality.

The insurance company sends the physician a warning before an audit. “Please pull out charts on these ten patients,” and then one morning the auditor, often a nurse, shows up to look at those ten charts. If you’ve ever seen bank examiners at work, I think the two are pretty interchangeable. The only difference is there are just a couple of government agencies currently doing bank audits, but more than a dozen large insurers, along with Medicare and Medicaid, are regularly performing audits.

The goal of the auditor is straightforward. She’s looking for evidence that the doc might be charging the insurance company for more services than the chart notes indicate. If the auditor sees a trend, she’ll ask for more charts and, ultimately, the doctor will receive a certified letter requesting a refund for what the insurance company regards as “billed for but not provided.” Physicians call this a clawback. The insurance company isn’t actually saying the physician committed deliberate fraud, but the threat is implied if it doesn’t receive its refund check.

Curiously, both parties generally agree that all this is most often a misunderstanding of the incredibly complex US billing and coding regulations, but in the end the result of an audit is either neutral or in favor of the company. In the history of medical audits, no physician has ever heard, “Why, doctor, you’re doing such a good job with your patients, and spending so much time, that you’re really not charging us enough. We probably owe you thousands of dollars! Please let me send you a check as soon as I get back to the office.”

Back to the emergency room
The 17-page report on your emergency room visit is nothing more than a primary care office visit on steroids. EMR software systems can magically transmogrify what should be a fairly simple physician-patient encounter into an interaction as complex as a visit to Mayo Clinic. Emergency rooms are expensive to run, requiring a cash flow many multiples higher than a primary care office visit. What better way to boost revenues than an EMR system that produces a report that can both generate maximum dollars and satisfy every conceivable requirement in the auditor’s policy manual?

Obviously, the cost overruns with health care like this can be mind-boggling.

Even though the report on you that I receive is 17 pages long, do you honestly think that some poor soul sat down and wrote 17 pages about your cold? The secret’s in a software creation called a template. Maybe you work somewhere where you use templates, pressing CTRL + 1 or more additional keys to fill whatever you’re writing with lots of verbiage. Form letters are templates. Write to your Congressman about the environment and some clerk enters your name, hits two keys, and an entire personalized-looking response appears in your inbox.

EMRs provide doctors with templates for everything imaginable needed for a chart. You come in with a cold and the doc writes an entire SOAP note with a keystroke. If there’s too much detail or not enough, she can edit the template to suit her needs. The template system can also be personalized to offer diagnostic test suggestions (blood count, chest x ray) that may or may not be acted on. A newbie in an ER–say a medical student fearing malpractice or labeled sloppy by his senior resident–tends to follow all the template’s suggestions. If your x ray is mildly unusual (an old scar is seen, for example), this can result in the student measuring your blood’s oxygen level, ordering a CT scan of your chest, and/or referring you to a pulmonologist.

EMRs with their templates generate beaucoup bucks.

(Templates can also lead to careless mistakes. The doctor can hit the “Normal Female Exam” template for a 30-year-old man, and since EMRs cannot be altered, the poor man forever carries a record of having a normal pelvic exam.)

If you’re already in the hospital’s system when you visit the ER with your cold, all the previous medical problems in your records will immediately pop up in your ER notes. The ER doctor will comment on each of these, usually with a SOAP note. All your diagnoses (even those from years earlier) will appear on your emergency room discharge diagnosis sheet to maximize billing. Many templates add a paragraph on the side effects of each of the meds you’re taking (or ever took), contributing line after line to the 17 pages of your ER visit.

Finally, after you’ve been examined, tested, x-rayed, and indeed the docs says you have a bad cold, you’ll be given about five pages of self-care instruction, also part of the fax hurrying out of my machine. These often read as if written for illiterates, with simple words, stick figures, and the like. I suspect the hospital’s legal department reviews each page with a magnifying glass before approving.

On these instruction pages, you’ll learn to take an aspirin if you feel achy, blow your nose using a tissue, and dispose of the tissue properly. You’ll learn the most up-to-date coughing technique (into the crook of your arm) and, if you think you’re near death, to dial 911.

Why all this busy work?
Why, instead of talking directly to you and making actual eye contact, are the doctor’s fingers flying across his keyboard, inserting (and editing) template after template?

You’ve figured this out by now. Because with each diagnosis, the ER doc is allowed to add a billing code, which can then be submitted to your insurance company so the doc (or rather his hospital employer) will be paid more money. Actually, the doctor himself is usually a salaried employee, totally oblivious of the billing process he’s participating in.

In 1957, if you visited a family doctor with a cold the visit would set you back $10 cash, your prescription cough syrup maybe another $2. By the 1970s, the visit had increased to $45. And today, by generating paragraph after paragraph of meaningless filler into your medical records, a visit to your doctor’s office visit may run around $150.

But that 17-page ER visit, with all its template-recommended bloviating and review of all your records, comes to about $5000.

Just take an aspirin and blow your nose.

Be well,David Edelberg, MD

PS The immediate-care centers you see everywhere are actually much more efficient. They, too, will fax me details of your visit, usually two to three pages max. I have no idea how much they bill your insurer for a visit, but since the immediate-care industry is doing well, they must be making someone (namely the insurers) happy by charging lower fees than emergency rooms.

Your articles on these topics are much appreciated. As a patient I am fully aware of this situation. I have just had two visits two the ER in the past week for a severe respiratory condition. Unfortunately my Physicians Assistant who is my primary care provider still has not been able to get a copy of the ER doctor’s notes and it has been almost a week since the first visit. Even though my O2 sats were hovering between 84-90 with a few peaks of 94, I couldn’t get oxygen prescribed. In the past five months since my last Bronchitis attack i have become bedridden, lost 30 pounds and was unable to eat at all, but I have had a hard time convincing anyone that this is true. They will only deal with the present condition. I believe all of this was caused by hypoxia, but proving it and getting oxygen, even for ten minutes was impossible. Finally the PA was able to get me doped up on steroids sufficiently that my O2 sats came up into the low 90’s. But what a struggle. I didn’t understand because I was a home health care worker for an elderly gentleman about ten years ago and he was always given 02 in the ER when his sats went below 90. No questions asked. But now they have dropped the requirement to 88% sat. Everyone told me oxygen is just too expensive to prescribe and too difficult to prescribe and it is best to have a pulmonologist prescribe it. I was severely stressed and exhausted from the exertion that was required for me to get a breath. We don’t have a regular pulmonologist where I live so it took one urgent care visit, three doctors office visits, and two ER visits to get an x-ray and open my airways so I could breath, eat and get out of bed. No one wanted to give me an x-ray to determine the cause. Because of that one doctor diagnosed me as pneumonia, another as bronchitis. The assumption was “this is a bug that is going around no big deal” and the implication was that I was being difficult. The reason this has persisted so long is because my previous Doctor has only 15 minutes to see me and will only deal with the #2 complaint in your SOAP. And he is irritable and loses his temper. He would not even listen when I tried to tell him I had never gotten well after the first bronchitis episode. He told me he was busy, had other patients and I would have to schedule another appointment to talk to him about “unrelated matters”. He refused me a chest x-ray as he had done during the first bout in October. When I finally got my chest x-ray it shows COPD. The ER doctor pointed out that my diaphragm is flat and he could see 11 ribs when he should only see maybe 8. I have suffered needlessly for years with this because of the unwillingness of my doctor and others to give me a simple, inexpensive chest x-ray. Instead what I got four years ago (following a serious bout with pneumonia that would not clear up) was a diagnosis of CFS and a referral to counseling, but no tests to confirm the diagnosis. It has become painfully apparent to me that the Insurance companies and managed care administrators are controlling our doctors and the way medicine is practiced and dispensed with one objective in mind: maximize profits by minimizing costs. I have excellent medical insurance, but since Medicare has become my primary insurance, I am having trouble getting services and my poor doctor (a new one) spends most of her time trying to figure out what she can prescribe that will be paid for by my insurance company. What is even worse is that some things I need would be available if I were on Medicaid, but I can’t get the service because I am on Medicare. Being told that at my age after years of paying taxes is very disconcerting. And yes, I have the same complaint as others, she spends more time messing with the computer input than she does looking at me. And even though I had all my records sent over, she has never looked at them because they are not in the computer and I am sure she doesn’t have time. Fortunately she kept me in a room for over two hours, while she monitored me and determined the best treatment and while she continued to see her other patients. Well it worked and I can breathe this morning, I am able to get some food down and I am beginning to be able to get out of bed again. But what a nightmare, not just for me but also for my PA.

Tara’s experience of too few tests or tests coming too late, as well as lack of access to a successful therapy (oxygen), is much more in line with my experience than too many tests, which I often hear complaints about. Had I been tested properly and on time, I would have been spared nearly 20 years of unnecessary illness. Back to EMRs: I teach people in healthcare how to use these, and I can certainly attest to the fact that they generate a lot of paper, the opposite of what they were supposed to do. And those of us at the end of the food chain (the trainers) truly believed that EMRs would be most helpful–that they could be read across systems, so that if, for example, you got hit by a yellow taxi while vacationing in NYC and ended up in a coma in an ER far from home, your basic data such as required daily meds and allergies, could be quickly looked up and your life would not be unnecessarily threatened by lack of knowledge. I’m not sure how things got so complicated, but it would not be the first time that the private sector, in this case insurance companies and the vendors who make the EMRs, saw an opportunity, jumped in and took over large portions of the process. I still think EMRs are a good idea–and I do like the convenience of my own patient portal–but the records do indeed need to be more brief and someone needs to decide who owns them and how they are best and most efficiently used.

A recent visit to a cardiologist involved my sitting near him and watching him silently look at a screen as he was typing furiously.
While this was happening he did not speak to me, but later I found out he had written reams on the small keyboard in his lap.
Much of the information he learned by reading the screen was inaccurate, so what he wrote followed in the same line of error.
What can be done to correct the errors contained in the EMR, particularly the lie that I had never taken the medication?

Hi Nancy
What you described simply defines health care in 2015, especially with the doctor’s reliance on old and incorrect information from previous notes. There are still doctors who dictate their notes and then hire a secretarial service to do all the typing. I imagine with some detective work, or simply calling cardiology offices and asking if the doctors dictate their notes, you’ll find someone to make eye contact with you rather than a computer screen

It’s a wonder any of us live through the American health care system! This points out that the greatest flaw in the ACA is that it kept the profit motive in medicine and medical insurance alive and well.
It also reminds me of how computers were going to lead us to paperless offices. Everyplace I’ve worked the opposite has happened. Computers just make it easier to print things, and we end up with far more paper than we ever had when we wrote or used a typewriter (even with a carbon).
A big thank you to Dr. E and the other dedicated physicians who continue to care for and about patients even while dealing with this morass of absurdity.

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